PrevMed2016-11-08T20:55:10Zhttps://prevmed.org/feed/atom/WordPressprevmedadminhttp://www.prevmed.org/?p=5412016-08-22T16:41:30Z2016-08-22T16:41:30ZSource: American Academy of Audiology

Report of the Task Force on Hearing Impairment in Aged People

Background

One of the demographic imperatives affecting the United States’ present and future course is the aging of Americans. The number of persons aged 65 years and older is growing more rapidly than the rest of the U.S. population.20 The expansion of the nation’s aged population has considerable implication for health status, health care utilization, and health care delivery.

Hearing impairment is the third most commonly reported chronic problem affecting the aged population.17 At present, more than 7 million aged persons suffer from some degree of hearing impairment.8 Given the rapid growth in the population over 75 years of age, it is projected that more than 11 million members of this age group will have significant hearing impairments by the turn of the century. The aging of the population will be accompanied by an increase in the prevalence and severity of hearing loss, due to the direct correlation between age and hearing loss.

Presbycusis often is defined as hearing loss associated with the aging process. However, the Committee on Hearing, Bioacoustics and Biomechanics3 considers presbycusis to be the sum of hearing losses which result from several varieties of physiological degeneration. These include insults due to noise exposure, ototoxic agents, polypharmacy, and medical disorders as well as the effects of physiological aging3. Irrespective of the etiology, the interference with communication created by sensorineural hearing impairment has profound negative effect on the lives of aged persons. In addition to its threat to personal safety, hearing impairment has an adverse effect on physical, cognitive, emotional, social, and behavioral function.15,1 These manifestations are often viewed by the hearing impaired person as representing a very significant handicap, despite the audiologic appearance of a relatively mild hearing loss.15 Fortunately, the negative influences of hearing impairment are amenable to intervention.15 Hence, hearing health care professionals must strive to identify individuals with hearing impairments in order to remediate the permanent impact of hearing loss.

Identification of Impairment in the Aged Population

The U.S. Preventive Services Task Force21 has recommended that aged persons be screened for hearing impairment. The goal of any screening program is to reach as large a proportion of the eligible target population as possible. To this end, a number of potential settings are available for screening aged individuals for hearing impairments and handicaps. Potential settings for screening include health fairs, community based programs, primary care physician’s offices, acute care settings, nursing facilities and possibly the home. Each of these settings has advantages and disadvantages, with the limiting factors in any screening setting being ambient noise level, professional resources available to administer the screen, and money available to purchase the requisite equipment. Nevertheless, a screening program should use tools that are appropriate for the particular setting, and should employ professionals who are well trained to perform the screen. Screening conducted in the offices of primary care physicians is particularly attractive because most persons over 65 years old visit their primary care physician on an annual basis and the office may provide a relatively quiet setting for screening.

A number of screening tools are available to detect clinically important hearing impairments and handicaps in aged people. An impairment is defined as “any loss or abnormality of psychological, physiological or anatomical structure or function,” whereas a handicap is “a disadvantage for a given individual resulting from an impairment that limits or prevents the fulfillment of a role that is normal for that individual.”24 Screening tools designed to detect hearing handicaps and impairments fall into two broad categories: hearing handicap scales and audiometric screening. Hearing handicap scales assess the perceived effects of hearing loss on various aspects of daily function. A screening version of one such scale, the Hearing Handicap Inventory for the Elderly (HHIE-S), is a reliable and valid method for identifying handicapping hearing impairment among aged persons.12,15,23 The sensitivity and specificity rates of this tool are approximately 70 to 80% for identifying hearing losses of moderate or greater degree.

An audiometric screen is a quick and valid method for detecting hearing impairment among aged individuals. Screening for hearing impairment requires the use of one of two methods: 1) a calibrated audiometer in a quiet environment, or 2) an otoscope with a built-in audiometer (e.g. audioscope). The advantage of using a calibrated audiometer is that it is a valid and reliable technique. The requirement of a quiet environment, however, may not be practical in all settings. The audioscope delivers selected frequencies (500, 1000, 2000, and 4000 Hz) at one of three intensities to the entrance of the ear canal. The audioscope has an overall accuracy for hearing screening of 75-80%.2,5,13 Screening with both a hearing handicap scale and either an audiometer or audioscope is recommended,22 because the correlation between hearing impairment and handicap is imperfect.18 Thus, combining the two techniques may increase the overall accuracy of the screening program.12

Once identified through a screening program as being likely to have a hearing impairment or handicap, an aged person should be referred to an audiologist for thorough audiologic evaluation and appropriate recommendations for aural rehabilitation. Medical clearance should also be obtained to rule our pathological conditions that would contraindicate hearing aid use. Unfortunately, the rate of compliance with the recommendation for further audiometric evaluation among aged persons can be as low as 50% and ranges between 50 and 90%.10,11,19 Moreover, in most circumstances, only 10 to 20% of this population subsequently obtains hearing aids. Barriers to compliance include confusion about the hearing aid delivery system, the cost of evaluation and hearing aids, social stigma, unwanted amplification of background noise, and myths about the efficacy of hearing aids.6 An integral part of any screening program should be mechanisms to enhance the probability that individuals will comply with referrals for additional evaluation and remediation.

Strategies for Intervention

The audiological evaluation establishes the need for possible aural rehabilitation and medical evaluation. In most cases, the aged person’s auditory capabilities can be assessed with standard audiometric techniques. Occasionally, the behavioral assessment must be modified to accommodate physical or cognitive limitations of aged individuals. The typical presbycusic hearing loss is sensorineural, sloping, and ranges in degree from mild to moderately-severe.7,14 Moreover, pure tone sensitivity tends to deteriorate with age, and males exhibit poorer thresholds than females of comparable age.7,14 The hearing loss observed in older people often limits their reception of conversational speech, especially in noisy environments.4 While the typical presbycusic hearing loss is not amenable to medical intervention, the handicapping effects of the hearing impairment often can be remedied successfully with selected audiologic intervention strategies.

Hearing aids are the principal resource for improving communication and reducing handicaps in aged people. Hearing aids amplify speech so that it becomes comfortably audible to the hearing-impaired user, but does not exceed the user’s tolerance level for loud sounds. Significant improvements in hearing aid design have enabled greater flexibility in selecting hearing aids for the typical hearing loss patterns associated with aging. The newest generations of hearing aids includes digitally controlled analog designs. In addition, hearing aids can now be modified to ease manipulation of volume controls, battery compartments, and switches, thereby improving hearing aid use for aged individuals with manual dexterity problems. Recent evidence indicates that hearing aids successfully reduce the social, emotional, and functional handicap often resulting from hearing impairment in aged people.15

In addition to hearing aids, assistive living devices can be used effectively by aged people to improve communication in specific situations. Assistive listening devices transmit acoustic signals by wire, magnetic induction, infrared light or radio frequency. They are particularly useful when room acoustics are poor. The use of assistive devices is expanding in theaters, public meeting rooms, and houses of worship. They can be adapted for use in personal living areas and common areas of nursing homes where communication may be difficult.

Alerting devices, which use lights to signal fire alarms or the telephone or doorbell ringing, can reduce the hazards to safety imposed by the hearing loss. Telephone amplifiers with adjustable volume controls are becoming an integral part of many new telephone designs. The television caption decoder can be used by those with reasonable vision, but whose hearing is limited despite rehabilitation. Assistive listening and alerting devices are effective, and their use should be encouraged in hospitals, nursing facilities, and the home.

Hearing aids should be within the greater context of aural rehabilitation. Aural rehabilitation includes any non-medical rehabilitation. Aural rehabilitation includes any non-medical intervention designed to remediate hearing loss and improve communication. It also includes counseling the hearing-impaired person and his or her family about the implications of hearing impairment, as well as conducting a hearing aid orientation and follow-up to ensure proper hearing aid use. Suggestions for maximizing the use of visual cues and residual hearing are provided. Formal speechreading instruction or auditory training may be recommended to enhance the information received through amplification.

The aural rehabilitation process should include not only the aged hearing-impaired person, but a family member or significant other as well. For the aged individual to achieve maximum benefit, the family and health care staff must appreciate the impact of the hearing impairment, the operation of the amplification device, the benefits and limitations of the procedures being used, and their own role in improving and promoting communication.

Role of the Audiologist

The audiologist is the primary hearing health care provider for aged individuals with hearing impairment. An audiologist is a person who, by virtue of academic and clinical training, and appropriate certification and/or licensure, is uniquely qualified to provide a comprehensive array of professional services relating to the prevention, evaluation, and rehabilitation of auditory impairment and its associated communicative disorders. The audiologist may provide these services independently or as part of an interdisciplinary professional team involved in identification, diagnosis, and treatment of individuals who have disorders related to auditory dysfunction.

The audiologist serves as the primary expert in the assessment and non-medical diagnosis of auditory impairment in aged people. Assessment includes, but is not limited to, the administration and interpretation of behavioral, electroacoustic, and electrophysiologic measures of the status of peripheral and central auditory systems and measures of hearing handicap. Methods of assessment include hearing-handicap scales, pure-tone audiometry, immittance audiometry, speech audiometry, and auditory evoked potential measurement.

Audiologists are uniquely qualified to provide a full range of auditory rehabilitative services to aged individuals. The audiologist is the primary individual responsible for the evaluation and fitting of all types of amplification systems, including hearing aids and assistive listening devices. The audiologist determines whether the aged individual is a suitable candidate for an amplification system, evaluates the benefit that the individual may expect to derive from such systems, and makes an appropriate recommendation. In connection with such recommendations, the audiologist may take ear impressions, fit and dispense the amplification system, and provide counseling regarding its use.

The audiologist also provides rehabilitative services and education to individuals with auditory impairment, to family members, and to the public. The audiologist provides information concerning hearing and hearing impairment, the use of prosthetic devices, and strategies for improving speech recognition by exploiting auditory, visual, and tactile speech information. The audiologist also counsels patients regarding the effects of auditory impairment on communicative and psychosocial status. In addition, the audiologist determines the need for additional aural rehabilitation and, if indicated, the nature of the rehabilitation program. In connection with such determinations, the audiologist may conduct individual and/or group rehabilitation programs.

The audiologist serves as an advocate for aged individuals by encouraging equal access for those with communicative disorders, by prompting “self-help” consumer groups, and by encouraging third-party reimbursement of audiological services. The audiologist should be an integral member of any multidisciplinary team involved in the evaluation of the social, psychological, physical, and mental status of elderly people. The audiologist also serves aged people by promoting awareness of hearing impairment, available audiological services, and available remediation devices and programs to the hearing-impaired individuals, their spouses and children, and to other caretakers who constitute their support system.

Recommendations

The membership of the American Academy of Audiology seeks to maximize communication skills in aged hearing-impaired individuals. A comprehensive approach for providing effective services to aged individuals involves cooperative efforts among a variety of professional organizations and specialists. As a consequence, the Academy membership actively pursues close professional ties with other gerontology specialists toward meeting the hearing health care needs of aged people.

The American Academy of Audiology has developed five recommendations for improving the quality of life for hearing-impaired aged individuals.

The Academy advocates the use of screening procedures for identifying persons with hearing impairment or hearing handicap. Screening procedures should be used to identify the greatest number of hearing-impaired aged people. Screening should be coupled with efforts to maximize compliance with referral recommendations for audiologic or medical evaluation.

The Academy promotes the provision of high quality audiological services for aged people. State-of-the-art knowledge and technology should be applied in the evaluation of hearing impairment in aged individuals as well as in the selection of aural rehabilitative procedures, including hearing aids, for aged individuals.

The Academy promotes funding for research on hearing impairment and aging by government agencies and private foundations. Critical issues that need investigation include prevention of age-related hearing loss, understanding the auditory degenerative processes that account for age-related hearing loss, improving the design of hearing aids to overcome specific speech understanding problems of aged people, and developing valid outcome measures of audiological management strategies.

The Academy promotes equitable third-party payment from insurance companies, retirement health plans, state agencies, and federal agencies for hearing-related services and devices for aged people. The limited financial resources of many older people often restrict access to effective audiological services and therefore prevent them from receiving the benefits of a hearing aid.

The Academy promotes public education about hearing impairment in aged Americans. Practical information and suggestions should be provided to this group, including warning signs of hearing loss, where to go for help, and the benefits of amplilfication. Common misconceptions about hearing impairment and hearing aids also need to be dispelled. The Academy was founded in 1988 to “improve service to the hearing impaired by advancing the highest professional standards for diagnosis, habilitation, rehabilitation, and research in hearing and its disorders.” These guiding principles apply specifically, and most importantly, to aged individuals, because they comprise more than half of the hearing-impaired population in the United States and their numbers are increasing dramatically. The American Academy of Audiology is committed to fostering excellence in hearing health care for senior citizens.

National Center for Health Statistics (NCHS) (1987). Current estimates from the National Health Interview Survey: United States, 1987, Vital and Health Statistics, Series 10. Public Health Service, Washington: U.S. Government Printing Office.

World Health Organization (WHO) (1980). International Classification of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequences of Disease. World Health Organization, pp 25-43.

CHICAGO, OCTOBER 1 – A new report examining factors impacting the oral health of older Americans reveals the nation’s oral health is in trouble. Published by Oral Health America (OHA), A State of Decay, Vol. III is a state-by-state report of the oral health of its 65+ population and the success or failure of states to address those needs. OHA found the lowest-performing states are found in the South and highest-performing throughout the East and the West coasts as well as the Midwest. The report underscores the important role policies and practices play in addressing barriers, particularly for vulnerable populations.

“While many Americans face obstacles when it comes to oral health, older adults are at an increased risk due to challenges with accessing care,” said Dr. Dushanka Kleinman, a dentist and associate dean for research and academic affairs at the University of Maryland School of Public Health. “We have to develop solutions at the practice and policy level to address the barriers older Americans experience.”

Older Americans are at risk for adverse oral health for a variety of reasons. Among the most prominent are a general decline in health, less access to oral healthcare and lack of dental benefits. The report serves as a resource for states to address shortfalls in oral health status, dental benefits for low income adults and population-based prevention, all of which affect the oral health of older adults.

A State of Decay gave a rating of “poor,” “fair,” “good,” or “excellent” based on state level data analyzing seven variables impacting older adult oral health: edentulism (loss of teeth), intake of fruit and vegetables, the availability of Medicaid dental benefits, Community Water Fluoridation, the status of the state’s older adult Basic Screening Survey and the existence and extent to which the State Oral Health Plan includes immediate or recent efforts to improve the oral health of older adults.

OHA identified variables for those ratings based on the latest understanding of what contributes to the condition of oral health among older Americans. Each state has been given two scores–an Individual Oral Health Score that measures individual-level factors that address the oral health of older adults such as edentulism and nutritional intake and a Public Policy Score, which measures factors that address what states are doing to address the oral health needs of older adults. These scores have been combined to give a total Composite Score.

The final evaluations for all 50 states revealed that 74 percent, or 37 states, earned a Composite Score of “fair” (30 percent) or “poor” (44 percent). Puerto Rico, Guam and Washington D.C. were rated on some but not all of the variables, therefore not included in the Composite Scores.

All seven variables were combined in the Composite Score to provide an overall ranking. In order, the 10 states with the highest Composite Score are Connecticut, Rhode Island, Virginia, Minnesota, New York,
Colorado, Florida, Maryland, North Dakota and Wisconsin. The states with the lowest Composite Scores are Montana, Pennsylvania, Arkansas, Hawaii, South Carolina, Oklahoma, Louisiana, Tennessee, Alabama while Mississippi’s was least favorable.

The top findings of this report that illicit further scrutiny and action are:

Tooth loss remains a signal of suboptimal oral health. Eight states had strikingly high rates of edentulism, with West Virginia notably having an older adult population that is 33.7 percent edentate

Poor nutritional intake affects America’s seniors. Forty percent (21 states) have 40 percent or more older adults who do not eat at least one serving of fruit a day. Puerto Rico (51.3 percent), Arkansas (50.5 percent) and Oklahoma (50.4 percent) represent the highest rates with over half of older adults who are not eating at least one serving of fruit a day

Communities without fluoridated water create deficiencies in prevention. Eight states (16 percent) still have 50 percent or more residents living in communities unprotected by fluoridated water. Hawaii (89.2 percent) and New Jersey (85.4 percent) have the highest rates of residents living without fluoridated water

Inadequate surveillance of the oral health condition of older adults persists. Forty-five percent (23 states) have never completed a Basic Screening Survey (BSS) of older adults and have no plan to do so. An older adult Basic Screening

Survey is a surveillance of the oral health conditions of seniors in community and long-term-care settings. The BSS is, recognizes the need for community level oral health status and dental care access data

Persistent shortage of oral health coverage. Forty percent of states (20 states) provide either no dental benefit or emergency coverage only through adult Medicaid dental benefits. Eighteen states provide limited coverage and twelve include comprehensive coverage

Critical lack of strategic planning to address the oral health of older adults. Seventy percent (35 states) lack a State Oral Health Plan that mentions older adults, with 13 states lacking any type of State Oral Health Plan.

“Access to oral healthcare for older Americans is a matter of social justice, with those living in poverty suffering the most from the lack of publicly funded benefits needed to improve their oral and overall health,” said Dr. Caswell Evans, Associate Dean of Prevention and Public Health Sciences at the University of Illinois at Chicago School of Dentistry.

OHA developed six key practical recommendations to promote healthy aging and independence for this rapidly growing cohort of America’s population.

Support the Reauthorization of the Older Americans’ Act, S.192, in the House of Representatives and the implementation of the oral health screenings provision

Support caregivers, often responsible for ensuring the oral health of their loved ones, through the passage of the RAISE Family Caregivers Act

Advocate for financially viable publicly-funded dental benefits

Sustain Community Water Fluoridation as an evidence-based public health practice that positively impacts oral health at the population level

Include specific language to ensure inclusion of provisions for older adults in every state’s Oral Health Plan

A State of Decay 2015 is the third in a series of reports from OHA surveying the state of oral health for older Americans. It is one of five programmatic strategies of OHA’s Wisdom Tooth Project®, a program designed to meet the oral health challenges of a burgeoning population of older adults with special needs, chronic disease complications and a growing inability to access and pay for dental services.

Links to the latest volume of A State of Decay and earlier editions can be viewed on toothwisdom.org.

ABOUT OHA’S WISDOM TOOTH PROJECT
For 60 years, Oral Health America has been the leading national non-profit dedicated to improving the oral health and well-being of Americans throughout the entire spectrum of life. Over the decades, the organization has evolved and adapted to the dynamic nature of our country’s demographics and specific health needs. The Wisdom Tooth Project was born in 2010 due to the current and future implications of an aging population and the need for oral health resources which mean that we must take meaningful action now.

ABOUT ORAL HEALTH AMERICA
OHA’s mission is to change lives by connecting communities with resources to drive access to care, increase health literacy and advocate for policies that improve overall health through better oral health for all Americans, especially those most vulnerable. Through Smiles Across America®, which serves 460,000 children annually, the Wisdom Tooth Project®, which reaches tens of thousands of older adults, and the Campaigns for Oral Health Equity, which prioritize oral health alongside other chronic diseases, OHA helps Americans of all ages to have a healthy mouth and to understand the importance of oral health for overall health. For more information about Oral Health America, please visit www.oralhealthamerica.org.

® Smiles Across America and Wisdom Tooth Project are both registered trademarks of Oral Health America

Poor or neglected feet often lead patients down the path of ulceration, infection and amputation.1 People with diabetes are at higher risk for these sequelae. Up to 25 percent of the diabetic population will have at least one foot ulceration during their lifetime with 85 percent of lower-limb amputations being preceded by an ulcer.2,3

The latest Centers for Disease Control and Prevention (CDC) National Diabetes Statistics Report (2014) reported 29.1 million people (9.3 percent) in the United States have diabetes.4 The cost of treatment of diabetes and its complications in the United States in 2007 was approximately $116 million with 33 percent of that amount going toward ulcer treatment.3 This number is likely to increase as the diabetic population continues to grow with current estimates suggesting that diabetes will affect 366 million people worldwide by 2030.1

The purpose of this article is to remind us, as podiatric physicians, of the often underappreciated and perhaps sometimes forgotten importance of routine diabetic foot care. Although nail pathology may not be the most glamorous aspect of podiatry, it is our “bread and butter” and we need to be experts in providing this service to our patients.

How Nail Changes Can Lead To Ulcers

There are several pathways to ulceration in patients with diabetic neuropathy, ranging from biomechanical issues causing calluses to stepping on a foreign body. One pathway toward ulceration that we may overlook is the dystrophic, mycotic and neglected toenail. Dystrophy in the toenail can be a manifestation of hereditary, congenital or acquired conditions.

In the patient with diabetes, the origins of ulcers lie in microtrauma or changes in the vascular and nutritional supply to the toenail. Onychomycosis results from dermatophytes (most notably Trichophyton rubrum and Trichophyton mentagrophytes), yeasts (Candida albicans) and non-dermatophyte molds.5,6 It is this thickened nail that causes injury to adjacent skin (whether on the same toe or neighboring toe, known as a “kissing ulcer”) and can erode the nail bed and hyponychium, progressing to nail bed ulceration, paronychia, cellulitis of the skin or osteomyelitis to the underlying bone.7,8 The nail bed is a very thin tissue layer between two and five cells thick with the distal phalanx located directly beneath, putting it at increased risk of bone infection.9

Researchers have shown that one in three patients with diabetes has onychomycosis, making them 2.77 times more likely to develop onychomycosis versus people without diabetes.5,8 Authors have identified tinea pedis infection as another starting point and predictor of foot ulceration in the diabetic population.10Onychomycosis can precipitate tinea pedis and vice versa.10-12 Regardless of the starting mechanism, both fungal infections may lead to foot ulceration, cellulitis, osteomyelitis, gangrene and lower extremity amputation.13,14 Physicians can easily manage and treat onychomycosis and tinea pedis with scheduled podiatric assessment and intervention.

Predisposition to secondary (bacterial) infections may be a consequence of simply having diabetes. This is due to the multiple levels of compromise these patients have, whether it is diabetic peripheral and autonomic neuropathy, peripheral vascular and microvascular disease, immunosuppression, diabetic retinopathy, poor blood glucose control and/or a history of amputation.1,10,15 Even increased age, obesity and limited mobility can increase the potential for infection and are also obstacles to appropriate self care.5,15 Neuropathy prevents patients from feeling any trauma from the nail itself or shoe trauma that may be occurring in this local environment.

Additionally, approximately 20 to 30 percent of patients with peripheral arterial disease (PAD) have diabetes.16 The combination of the neuropathy, no feeling of any lesion development due to dystrophic, mycotic elongated toenails along with the vascular compromise will delay or prevent this lesion from healing. Ulcers stay open and exposed for a longer than ideal time, leaving them susceptible to colonization and infection.

Emphasizing The Role Of Toenail Debridement In Amputation Prevention

Sometimes as busy practicing podiatric surgeons, we forget that toenail debridement in the high-risk patient population is crucial in amputation prevention. Often our resident physicians do not even realize the importance until the patient comes in through the emergency department. At our institution, we provide routine care as an inpatient service often directed by the emergency room physician, primary care physician or infectious disease team. We find it important to stress to our residents, who are surgically driven, to remember the basics of what we do as well.

In a 1995 study, Reiber and colleagues showed that 7.5 percent of diabetic hospital admissions were caused by paronychia.12 The increased rates of onychomycosis in these patients may lend one to think the fungal infection to the nail had some effect. Improvement in foot care starting with debridement of toenail dystrophy and onychomycosis can reduce ulceration, cellulitis and infection rates. This can ultimately decrease complications arising from delayed diagnosis and their associated healthcare expenditures.2,15

Initially, it is important to evaluate these patients in the inpatient setting when possible or appropriate. Explain to patients their situation and stress to them the importance of personal at-home care as well as podiatric physician follow-up care after discharge. By having a podiatrist care for the nails, if a problem were to arise, treatments can start immediately to prevent for example, a neuropathic patient with PAD who cut himself from obtaining a chronic wound and infection. Morbach and colleagues, in an investigational study of 247 patients with an ulcer, found that 12 percent of those ulcers were attributed to “insufficient nail and foot care performed either by the patient, his family, or a professional.”17

In the Seattle Diabetic Foot Study, researchers compared the prediction of diabetic foot ulcer occurrence against certain risk factors and other clinical information in their study population.18 The presence of both tinea pedis and onychomycosis was statistically significant as a clinical finding relating to a higher risk of foot ulcers. Despite some of these fungal infections being treatable, diabetes and other comorbidities make this situation more limb-threatening. Interdigital maceration accounts for as many as 60 percent of cases of leg cellulitis while the fungal foot (toenails, interdigital or plantar) carries a significant risk for cellulitis (odds ratio 2.4) and is often a predictor for developing lower limb cellulitis.10,19

A study by Doyle and coworkers showed patients with diabetes and onychomycosis had a higher rate of foot ulceration, gangrene or a combination of the two.11 In their patient database study, researchers attributed 18 percent of gangrene and 10 percent of foot ulcers in patients with diabetes to starting with onychomycosis.

Elderly people who live in nursing homes are at greater risk for oral health problems compared to elderly people who live independently, according to a study published in the July/August 2002 issue of General Dentistry, the clinical, peer-reviewed journal of the Academy of General Dentistry (AGD).

Thanks in part to widespread fluoridation, more people than ever before are keeping their teeth throughout their lives. But as people age, medical complications and other factors can negatively affect oral health. Evidence shows that older Americans are at risk for greater oral health problems than other groups because of age and the inability to get to a dentist’s office due to an existing medical condition or lack of transportation.

“Oral health of frail elders residing in long-term care facilities is very poor, probably because access to dental services is limited,” says Francesco Chiappelli, PhD, co-author of the study. “Most of the care at nursing homes is medical care and nursing care, and sometimes the oral health needs are overlooked.”

Children or other relatives should take an active role in the oral health needs of elderly people residing in nursing homes. “Assisting with brushing, flossing and looking around the mouth for canker sores and abscesses can help ensure an elderly relative maintains their oral health, which in turn helps maintains one’s overall health. All oral health problems should be reported to the nursing staff for proper diagnosis and treatment,” says Dr. Chiappelli.

According to the report, greater awareness among health care providers and caregivers can do much to ensure the elderly receive good oral health care, primarily through assessments of the patient’s mouth.